3) I hereby give 40:31 Rehab & Wellness permission to evaluate and provide treatments to my child, and I understand there will be written, oral, and electronic communication between care providers/physicians, insurance companies, and 40:31 Rehab & Wellness staff. I understand that state representatives for the purpose of insurance certification or licensing and quality assurance may review my records. I understand that all practices of confidentiality will be followed in use of the information gathered.

40:31 Rehab & Wellness, PLLC offers Occupational Therapy services for patients referred to our practice. We are a licensed provider who develops individualized treatment plans to identify the services that will best suit your therapy needs. We will also work with your primary care practitioner to coordinate your care. Following the initial assessment visit(s), we develop a specific plan of care (POC) for review and approval by your child’s referring provider. Once your referring provider signs the POC, we can begin working with you or your family to improve your condition. We are pleased to serve your Occupational Therapy needs and encourage your feedback to alert us to anything we can do to provide you the highest quality of care. We require certain information from each patient in order to begin providing this care. The attached forms need to be completed in order for us to begin serving you as our patient. Please do your best to complete all the information. If certain information does not apply to you, please indicate that by noting “N/A” (“Not Applicable”) so that we know that you did not overlook anything. Each healthcare insurance payor has different guidelines for allowing coverage of Occupational and Physical Therapy services. Therefore, it is helpful if you let us know your healthcare payor when starting service so that we may find out if prior authorizations are necessary.

Private insurance companies may have limits on the amount of Occupational and Physical Therapy services covered. Once you have exceeded the financial limit of your benefits and you do not have additional healthcare coverage, you are responsible for the payment of your services. Additionally, private healthcare insurance payors have deductibles and co-payments for occupational therapy services that are the responsibility of the patient (or caregiver). While this practice will not discontinue your services for financial hardships, it is expected that patients pay at the time of service and/or set up payment arrangements. All payment arrangements are made at the discrepancy of an authorized representative of 40:31 Rehab & Wellness, PLLC. and must be signed by both parties to be considered a valid payment arrangement.

We communicate with our patients and/or guardians to resolve past due accounts in all cases. If we cannot reach a patient’s or their guardian by phone following the return of undeliverable mail, or if a patient payment agreement cannot be made or paid as agreed, we are forced to use the services of a professional collection agency. Once an account is placed with a collection agency, we cannot take the account back. Please let us know when or if your patient contact information changes so that we can always reach you, if needed, to discuss past due accounts.

New patients approved for Occupational and/or Physical Therapy services are responsible for any and all charges not paid for by healthcare insurance payors (Medicaid, private health insurance carriers, etc.). By signing this patient agreement, you are acknowledging that you understand this condition of service and commit to promptly paying 40:31 Rehab and Wellness, PLLC. for the services we provide to you, our valued customer. Following the receipt of your monthly patient statement, please contact our practice to make payment arrangements. We accept cash, personal checks, money orders, and credit cards (VISA, MasterCard, and Discover Card). We also are willing to make reasonable payment arrangements to keep your account current.

Welcome to our office! We are committed to providing you with the best possible care. If you have medical insurance, we are willing to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our financial policy. Payment, co-payment, deductibles, and co-insurance for services are due each visit for charges incurred up through your last visit. We accept cash, checks, VISA, MasterCard, and Discover Card. Please understand that you are financially responsible for all charges, whether or not they are paid by insurance. Please read carefully:

4. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. These particular services, if any, are your responsibility. Please note insurance companies may indicate the services were not medically necessary and claim that, because 40:31 Rehab & Wellness, PLLC is not a preferred provider, you do not have to pay the balance. This is NOT the case and you will be billed for the services. This office cannot accept responsibility for negotiating settlements on disputed claims.

6. Accounts that are past due will incur a finance charge at the rate of 10.5% annually. Again, our relationship is with you, not your insurance company. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact our billing department promptly for assistance in the management of your account. If you have any questions about the above information or any uncertainty regarding insurance coverage, please don’t hesitate to ask us. We are here to help you!

Our clinic strives to provide the best therapy services possible. In order to ensure optimal use of valuable therapy time, please discuss schedule changes at the end of your appointment with your therapist and the front desk administrator. We understand occasional changes are necessary due to illness, vacations, etc. Please call our office within 24 hours of a scheduled appointment if you need to cancel or reschedule that appointment. This allows for clients to reschedule into additional openings therapists may have. For Monday morning appointments, our office appreciates being notified no later than Friday noontime. This will allow other patients in need of care to be accommodated, as we have many patients. It is both unfair to the other patients and your child’s therapist to not allow for others to schedule in the open time slots.

40:31 Rehab & Wellness, PLLC is dedicated to maintaining the privacy of individually identifiable health information as protected by law, including the Health Insurance Portability and Accountability Act

(HIPAA). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. This information is referred to as ‘protected health information’ or PHI. We are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our organization concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.

The terms of this notice apply to all records containing your PHI that are created or retained by our organization. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our organization has created or maintained in the past, and for any records that we may create or maintain in the future. Our organization will have a copy of our current Privacy Notice posted in our office(s) in a visible location at all times. You may request a copy of our most current Notice at any time.

Treatment. Our organization may use your PHI to provide you with medical treatment. For example, we may ask you to have evaluations and we may use the results to assist in development of an individualized Plan of Care. Many of the employees within our organization, including, but not limited to, therapists, therapy assistants, case managers, educators, consultants, and administrative staff may use or disclose your PHI in order to provide competent medical treatment or to assist others in providing you with medical treatment. Additionally, we may also disclose your PHI to your primary care physician or other outside healthcare providers for purposes related to your treatment. Finally, we may disclose your PHI to family members or other who may assist in your care.

Payment. Our organization may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from our organization. We may contact your health insurer, including, but not limited to private, state, and/or federal organizations and providers, to certify your eligibility for benefits and to provide you with a detailed explanation of your benefits. We may also provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. You PHI may also be disclosed in order to obtain payment from third parties that may be responsible for such costs, such as family members. We may use your PHI to bill you directly for your services and/or items received from our organization. Lastly, your PHI may be disclosed to Medicaid and other payers or providers to coordinate and assist their billing efforts.

1. Maintaining vital records, such as births and deaths

2. Reporting child abuse or neglect

3. Preventing or controlling disease, injury, or disability

4. Notifying a person regarding potential exposure to a communicable disease

5. Reporting reactions to drugs or problems with products or devices

6. Notifying individuals if a product or device they may be using has been recalled

7. Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult persona served. We will only disclose this information if the person served agrees or we are required or authorized by law to disclose this information.

1. Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement.

2. Concerning a death we believe has resulted from criminal conduct

3. Regarding criminal conduct at our offices

4. In response to a warrant, summons, court order, subpoena, or similar legal process

5. To identify or locate a suspect, material witness, fugitive, or missing person

6. In an emergency, to report a crime (including the location or victim[s] of the crime, or the description, identify, or location of the perpetrator)

• An adequate plan to protect the identifiers from improper use and disclosure

• An adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law)

• Adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study or for other research for which the use or disclosure would otherwise be permitted.

Confidential Communications. You have the right to request that our organization communicate with you about your health and related issues in a particular manner or at a certain location. To request a type of confidential communication, you must make a written request to the Program Director or Privacy Officer specifying the requested method of contact, or the locations where you wish to be contacted. Our organization will accommodate reasonable requests. You do not need to give a reason for your request.

Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care of the payment for your care. We are not required to agree to your request, however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to provide you with medical treatment. To request a restriction in our use or disclosure of your PHI, you must make your request in writing to the Program Director or Privacy Officer. Your request must describe in a clear and concise fashion:

Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including medical and/or billing records, but not including psychotherapy notes. You must submit your request in writing to the Program Director or Privacy Officer for inspection and/or to obtain a copy of your PHI. Our organization may charge a fee for the costs of copying, mailing, labor, and supplies associated with your request. Our organizations may deny your request to inspect and/or copy in certain limited circumstances, however, you may request a review of our denial. Another licensed health care professional chosen by use will conduct reviews.

Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our organization. To request an amendment, your request must be made in writing and submitted to the Program Director or Privacy Officer. You must provide us with a reason that supports your request for amendment. Our organization will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion:

Accounting and Disclosures. All persons served by our organization have the right to request an “accounting of disclosures”. An “accounting of disclosures” is a list of certain non-routine disclosures our organization has made of your PHI (e.g. for non-treatment, non-payment, or nonoperative purposes). Use of your PHI as part of the routine care in our organization is not required to be documented. We are also not required to document disclosures pursuant to an authorization signed by you. To obtain an “accounting of disclosures”, you must submit your request in writing to the Privacy Officer. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six years from the date of disclosure and may not include dates before April 20, 2017. The first list you request within a twelve-month period is free of charge, but our organization may charge you for additional lists within the same twelve-month period. Our organization will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

Right to Provide an Authorization for Other Uses and Disclosures. Our organization will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorizations you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note, however, that we are required to retain records of your healthcare.